UNITING THE BUILT & NATURAL ENVIRONMENTS

Aging

In China, traditional Confucian values dictate that children take care of their parents in their old age. It’s taboo to put your parents in a home. But from 1979 to 2015, Chinese parents could only have one child, which means there’s a whole generation of Chinese with four grandparents and two parents to take care of. To get around the taboo, China Senior Care, a company based in Shanghai and Hangzhou, launched a Western-style senior residential care facility. The idea seems to be if a facility doesn’t seem typically Chinese, perhaps the stigma associated with placing an elder in a home will be avoided.

At the Environments for Aging conference in Las Vegas, Jane Rohde, principal with Baltimore-based architecture firm JSR Associates and Jerry Smith, FASLA, design principal at SMITH | GreenHealth Consulting, walked us through the brand-new Cypress Gardens, in Fuyang, a suburb of Hangzhou. The project, which took eight years, is a private, 5-star senior care center, with just 64 beds, some for assisted living and some for memory care for patients with neuro-cognitive disorders. Each room rents for about $5,000 per month. There are community spaces, restaurants, a library, a theater for both relaxation and entertainment. In fact, it replicates a traditional American senior care facility model: the car-dependent, self-contained suburban facility.

China, like the West is rapidly aging. According to the Brookings Institution, there will be nearly 250 million people 65 and older in China by 2030. Today, Chinese seniors are essentially cared for during “extended hospital stays,” said Rohde. “It’s OK if it’s called VIP care. But it’s really out of the 1950s,” with rows of beds packed into one room. It will be interesting to see how the culture and current senior care models evolves as the country ages.

Cypress Gardens sits on a steep suburban site in the side of a mountain, which meant major grading challenges for Smith, and his design-build partner, Yumin Li, ASLA, with POD Design, Shanghai. To deal with the slopes, Smith built in layers of stone retaining walls in the form of step terraces.

Retaining walls and terraces / China Senior Care

A winding drive leads visitors up to the upper level entry. Smith said working with multiple Chinese contractors (two for the building and interior and one for the landscape) was a new learning experience — “just getting the drive and entrance to meet each other was a challenge.”

Many of the rooms have their own terraces. And surrounding the base of the 6-story building are a series of “outdoor rooms,” both public and private, where residents can be alone or socialize, or engage in physical activities like Tai Chi.

Cypress Gardens terraces and outdoor spaces / China Senior Care

Smith said the owners “didn’t want the character of the space to be Chinese. They wanted all new, all Western.” A water fountain on the south wall cascades into a pool, in an effort to achieve the “Bellagio Wow!,” the owners said they wanted.

Still, Smith delivered a tasteful landscape that manages to be packed with a mix of Chinese and Western landscape elements, from pagodas, to a bosque of gingko trees, and a labyrinth.

An outdoor room / China Senior Care

The pagodas mark the transition from the larger public spaces to the quiet memory care spaces, and can be “closed off for privacy and security as needed.”

Chinese children paying to have their parents stay at Cypress Gardens will see a “wonderful place with very high-end amenities,” Smith said. The facility opens in next month and it’s already mostly booked.

When an older person loses their cognitive and motor functions, how do they maintain a connection to nature? This is the central question for Dr. Lori Reynolds, a clinical professor of occupational therapy, and landscape architect Brad Smith, ASLA. For a senior care facility in Phoenix, Arizona, with some 80 beds for assisted living and 30 for memory care, which involves helping those with advanced neuro-cognitive disorders, Reynolds and Smith together came up with new approaches to redo their courtyard in order to better maintain that connection. At the Environments for Aging conference in Las Vegas, they presented two options — one geared towards the assisted living residents and one for the memory care residents.

Reynolds made the case for investing in gardens in senior care facilities. “For 100 percent of older adults, nature is important.” As Jack Carman, FASLA, a landscape architect who works on senior care facilities, said: “our interaction with nature doesn’t end when we age.”

Reynolds found studies that show “access to nature increases resident satisfaction. And residents are most satisfied when there is ample seating, a variety of nature elements, walking paths, and adequate shade.”

Furthermore, the presence of a garden in a senior care facility influences those family members making the decision about where to put their parent or grandparent. “Nearly 50 percent report the availability of a garden influenced facility choice.”

Other surveys show that “outdoor activity space is among the top desired features,” and “the second most-important feature after the location.” So, if gardens make residents and families happy, and happy residents recommend a facility to others, than functional garden spaces seem like a no-brainer.

After explaining the many physiological benefits of nature for all people, she focused in on the benefits for those in memory care, explaining how exposure to nature can “reduce agitation and aggression among Alzheimer’s patients.” For these patients, “plants can become like people.” They are a presence that can take on “significant meaning,” Reynolds explained. Plants can also represent a legacy: A plant that has been in someone’s life for many years “is a past-life experience, and adds coherence.” The plant of a loved-one who has passed away can help sustain memory of that person.

Facilities can design ways to maintain this elemental connection — for both those who still have an active relationship with nature and those with a mostly passive relationship. For those able, an active relationship, which involves going out and spending time in the garden, is preferable. For those who cannot, a view out a window of a garden or even indoor potted plants are important. For some, “engagement outdoors may be too difficult — it may be too windy or too far from the bathroom.” But still, this doesn’t mean that accessible, aesthetically-pleasing gardens should be jettisoned from budgets.

The current state of garden design for senior care facilities is more focused on the internal than the external, “despite the acknowledged value of these outdoor spaces,” Reynolds said. If there are outdoor spaces, they are too often ornamental, not functional. More need to be accessible and provide healthy doses of nature.

To that end, Brad Smith worked with Reynolds and a senior care facility in Phoenix, Arizona, which they prefer to leave anonymous, to create garden designs that enable both more active and passive interactions with nature in an interior courtyard (see image at top). There are opportunities for transforming the space, which has a required access lane for a fire truck, into a more dynamic, therapeutic place that enables “inside out and outside in” connections.

The option geared more towards assisted living patients, offers a meandering path, an expanded covered patio and outdoor seating areas with rocking chairs, and a water feature surrounded by trees and plants. There are also bird and butterfly feeders patients can bring nectar and seeds to. For this option, Smith envisions caregivers bringing out wheelchair-bound residents so they can enjoy classes in the morning or early evening when it’s cooler.

For the variation designed for memory care residents, there are “vignettes designed to spark connections to the past.” Smith proposes making the space “as familiar as a backyard,” by designing a space for clothes lines and a gardening shed. “Women of a certain generation spent much of their time drying clothes; just letting memory care patients hang stuff up may make them feel better.” There’s already an old 1940s-era car parked in the courtyard, which he imagines male residents enjoy seeing and exploring. A loop walking path, inspired by the memory garden in Portland, Oregon, would enable chaperoned pacing. And the garden is also designed to provide pleasing views from inside the memory care residences of soothing water features.

With memory care, Reynolds said facility owners should use light furniture that’s easy for caregivers to move around. Also, pergolas should be avoided, as they throw shadows that will “wig out” residents. In Phoenix, the gardens will be really hot much of the day, with lots of glare, so use would be limited to mornings or evenings.

Smith and Reynolds estimated the senior care residence had spent about $57,000 on what they have now, which doesn’t do much. For $155,000 they could have the assisted living landscape, or for $96,000, the one for memory care. For just a little bit more, “they could have a killer garden space that boost marketing, creates positive first impressions and a sense of perceived value” while also providing many of the health benefits of nature, Smith explained. Bringing in volunteers — local Habitat for Humanity or other groups — to help plant could further reduce the costs. But they also noted a need for a maintenance budget up front.

Crotona Senior Residences, Bronx, New York / Rendering by architectural firm of record: Magnusson Architecture and Planning PC, via Welcome to the Bronx

Senior living communities can either be car-dependent and isolated, or an urban or suburban “destination for experiences,” with proximity to transportation, services, arts and culture, restaurants, shopping, and personal development opportunities. Which community would you want to live in? The answer was clear in a session at Environments for Aging in Las Vegas.

According to Michael Hass, managing partner, Drive Development Partners, who is also a member of the Urban Land Institute’s senior housing council, from 1990-2009, senior living communities, mostly geared towards the World War I-era “silent” generation, were all about providing “a sense of security, peace of mind, ‘safety in numbers,’ and belonging.”

But in 2009, occupancy across the senior living industry dropped. This was a key year, the first year baby boomers (those born between 1946 and 1964) became consumers of these places themselves, not just shoppers of these facilities for their parents. Their views on the traditional places could be summed up with: “I’ll never live in a place like that.”

Starting in 2009, senior living developers saw new demand among some of the oldest baby boomers for communities with “flexibility, choice, a unique variety of experiences, and spending opportunities.” They don’t want the self-contained campus, “35 acres in a cornfield.” Hass said: “They want an individualized experience, not the same formal dining room every day.”

Sean Thomson, senior living director, CR Architects, said a new model is needed to reach the 75-million-strong boomers, and walkable urban communities could be it. Walkable urbanism is in demand among all age groups, but is particularly appropriate for seniors.

A report from the George Washington University school of business found that “walkable urbanism is gaining market share.” Furthermore, there is a 90 percent premium for walkable office space, 71 percent premium for retail, and 66 percent premium for multi-family housing.

A 2013 report from Fannie Mae found senior communities with a WalkScore above 80, which means they are walkable, had a “relative risk of default that is 60 percent lower.” Those communities with a WalkScore below 8, which deemed them totally car-dependent, had a “risk 121 percent higher.” As Thomson explained, “walkable communities have a real human impact, but they also have real financial results.” Places with WalkScores in the 60 and 70s have some services in walking distance, but those with scores of 90-plus are ideal.

The ideal walkable senior community is basically found in dense European and Asian cities, or New York City. Imagine an apartment complex in a highly walkable environment, open to the surrounding neighborhood, with ground floor shops, cafes, and restaurants, and close to multi-modal transit opportunities, parks, plazas, self-storage facilities, and co-working spaces. Instead of all these services provided within an isolated campus, they are distributed through the surrounding neighborhood.

Thomson said an urban environment can provide better quality and a higher range of restaurants than any isolated senior community can. Embedding a senior community in a neighborhood also enables that inter-generational contact, social integration, and intellectual engagement so critical to “successful aging.”

Thomson summed up the benefits of walkable urbanism for seniors: “you don’t have to build the amenities; they are already there.”

To make these kinds of communities happen will take some creative housing development strategies. Senior housing developers can partner with medical groups, physicians networks, hospital districts, religious institutions, fitness or wellness companies, or become parts of existing mixed-use developments. “Senior living developers are almost never the top bidders so they need to be part of mixed-use projects, attach themselves to bigger projects.”

In revitalizing second-tier cities, senior housing developers have a real chance, particularly if they piggy-back on mixed-use developments where it’s advantageous to have a set of new fixed-income resident buyers all in one place. “Senior living communities can become an asset to a community.”

Also, Thomson can even see universities and colleges building nearby housing for retired alumni who want to return to the area.

They created a vision of a 2.5-acre urban senior development with medical facilities, spa, club, street-facing “fast, fresh” restaurants, shops, a playground, grocery store, and housing for 100-200 residents. “It wouldn’t be adult daycare, but a place where people enjoy themselves.” Perhaps this model could be deemed senior or grey urbanism?

When asked where this comprehensive vision is actually happening in the U.S., both Thomson and Haas said “some elements are happening incrementally, but not all together.”

“Dementia used to be viewed as a psychological problem, a mental illness. There was a stigma associated. Now, we know it’s an organic problem related to cell death in the brain. It’s a medical condition,” said P.K. Beville, founder of Second Wind Dreams, at the Environments for Aging conference in Las Vegas. Dementia, which includes diseases like Alzheimer’s, some forms of Parkinson’s, Lewy body disorders, and others, is now called a neuro-cognitive disorder. It affects more than 5 million Americans and their families.

Throughout the conference, perhaps the major focus was how to orchestrate a shift to more empathetic or patient-centric care for those with neuro-cognitive disorders. Just like with autism, it’s now understood there is a spectrum of neuro-cognitive disorders. One person with the disorder is really one person with the disorder. Designers, physicians, and researchers are partnering to better understand what it’s like to have a neuro-cognitive disorder and then create more sensitive processes and empathetic spaces that can help alleviate the pain these patients experience while institutionalized in memory-care facilities.

With these disorders, there is a loss of cognitive abilities. Our ability to hear, speak, read, and understand come from different parts of our brain. If there is cell death in these areas, then forging understanding connections with others becomes much more challenging. For many of these patients, long-term memory may be intact, but not short-term episodic memory. Also, semantic memory, which deals with abstract concepts, and procedural memory, which helps people remember how to get from point A to B, may be damaged. With the loss of abstract memory, “the goals or intentions of life is lost,” explained Terry Zborowsky, a researcher with HGA architects and engineers in one session, which is why they need “so many cues from the environment.” The loss of procedural memory means those care environments become incredibly confusing, so designers must be really thoughtful to make them more legible.

In her keynote, P.K. Beville said she wants caregivers to better understand why patients with neuro-cognitive disorders behave the way they do. When this is achieved, we can create spaces to better meet their needs. For example, Alzheimers patients in advanced stages “don’t get warning signals when they have to go to the bathroom.” All of the sudden it just comes on and they have to go. If the bathroom is far away, they may miss it and then be labeled incontinent and placed in briefs. “That’s a horrible threat to their dignity. How can we get them to their bathroom faster?” Some ideas: make the bathrooms more easily accessible via hallways, instead of hiding them, and put them in direct line of sight from beds.

Patients with neuro-cognitive disorders often have macular degeneration, which will put a large black spot in the middle of their vision. Their peripheral vision will also be significantly degraded. Their field of view is then limited to just a few feet, which is why they often look down to see where they are going. Beville said, knowing this, “it’s really silly that caregivers are still sitting to the sides of patients when they feed them. Imagine this fork flying out of space into your mouth.” When a patient balks or refuse to eat, they are then labeled difficult and that behavior gets “charted.” It makes much more sense to sit directly in front of the patient and create dining spaces that enable this.

In neuro-cognitive patients, degeneration of the reticular activating system is “what’s causing all the mess. It removes what’s important, causing a loss of focus. When this area of the brain is damaged, the brain picks up all sensory input, relevant or irrelevant.” These patients will hear everything — a door being slammed, a vacuum cleaner, a TV, and even the HVAC system. A dog barking or baby crying will be incredibly painful. When these patients are overwhelmed, they will begin to rock or become agitated. It’s important that memory care facilities then eliminate all sounds that can cause an annoyance. “The dining room can become a cacophony of sound. No wonder the residents don’t want to eat.”

Beville has created an amazing virtual reality tour that demonstrates what it’s like to have a neuro-cognitive disorder like Alzheimer’s. Working with leading medical professionals, researchers at Georgia Tech, and patients, she modeled the effects using goggles, which layers the effects of macular degeneration on whatever you are looking at; gloves that reduce fine motor skills; and headphones that mimic the aural sensory overload these patients can experience. Some two million caregivers in senior facilities have taken the tour.

At the conference, she modeled the newest iteration of the tour using Samsung Gear virtual reality (VR) headsets, instead of goggles, which augment a user’s field of view. The woman who tested it said it was a “terrifying experience.” She said she had “no perception of depth or peripheral vision; it was very hard to hear. I was very, very anxious.”

Studying the responses of the caregivers who have taken the tour, Beville found they exhibit the same behavior as those with Alzheimer’s and other neuro-cognitive disorders. They mumbled or hummed in an attempt to focus and block out the extraneous noises. They were agitated, wandered, rummaged, made negative statements that indicated they felt overwhelmed or depressed. Just 8-10 minutes in the headset caused some to have “strange or bizarre behavior.” Now imagine someone struggling with this condition for years.

Through the tours, Beville found older patients with this condition need “three times the light to see than younger people.” So facilities and their landscapes need to be well lit. The reaction time of the pupil is also delayed, so any changes in lighting causes major issues and should be avoided. Noise needs to be reduced to eliminate distractions. And patients want clear guidance — “something to do” — to help them focus.

After taking the tour, more caregivers agreed with the statement that neuro-cognitive disorder patients “don’t get the care they need.” The tours then help facilities begin to institute performance-based systems to improve quality of care. After taking the VR tour, caregivers say they will be “more patient and understanding with patients, will take more time and provide more attention, and communicate better.” Beville and her group are measuring the changes before and after sensitivity training to demonstrate improvements, which can be measured in adaptive behaviors among patients (engagement, communication, wayfinding, and social integration) and maladaptive behaviors (aggression, confusion, disorientation).

In another session, we heard how to take empathetic design to the next level. Architect Alana Carter, with HGA architects and engineers, explained how she checked herself into a healthcare facility she was redesigning, pretending to be a stroke victim with degraded capabilities on her entire left side. She was fed, washed, and helped in the bathroom. She called the experience “extremely humbling,” but it gave her insights into what needed to be done better from a patient point of view.

Carter and her colleague Zborowsky called for “walking in the footsteps” of patients first, using a comprehensive design methodology to uncover design solutions that will improve environments for aging. Their teams put GPS tracking devices on staff and patients and apply sensors that generate heat maps to understand the flow and popularity of areas in a facility. This kind of analysis can reduce inefficiencies in layout and help discover what features patients feel most comfortable around. Using VR headsets, HGA then prototypes Revit designs of new spaces in real-time, working with caregivers to optimize layouts and features. Finally, they test implemented designs through comprehensive pre- and post-occupancy reviews.

Carter concluded: “We need to move design for seniors out of the care facilities and into museums, galleries, movie theaters, and the home. We need to bring empathetic design to all places. We need to design for the outliers.”

The world is rapidly aging. According to Foreign Policy magazine, the share of the population 60 and older will nearly double to 21.5 percent by 2050, from 12.3 percent today. Aging populations will surge in Japan, South Korea, Germany, China, and the United States. The “‘grey tsunami’ will the defining feature of the 21st century.” By 2050, the median age in the U.S. it will be 42, while the global median will be 36. And the number of dependent people in America will also skyrocket from 49 for every 100 people of working age to 66.

At the Environments for Aging (EFA) conference in Las Vegas, which brought together senior living developers, architects, and landscape architects, along with physicians and caregivers, Debra Levin, president of the Center for Health Design, said 10,000 baby boomers (those born between 1946 and 1964) will turn 65 every day for the next decade. And these boomers have “different expectations about how and where they will age” than their parents, the World War I-era “silent” generation. Furthermore, these boomers are now living longer and want more control over their last years. They want more affordable solutions than increasingly expensive residential home care. The entire senior care industry will need to change to meet their needs and demands.

Dr. Roger Landry, author of Live Long, Die Short: A Guide to Authentic Health and Successful Aging, said “we can’t afford to make mistakes as the baby boomers age.” It’s important to promote “successful aging” strategies that can stave off long, slow declines due to illness, in favor of maintaining high levels of performance before a quick drop off at the end. The goal is to “die young as late as possible.”

He said all our cognitive performance will eventually drop after a long plateau that lasts from our 30s through out 60s. That decline is usually a “painful, degrading, and expensive experience.” But we can dramatically shorten the decline by using some smart approaches. About 70 percent of our ability to avoid the awful extended decline is tied to lifestyle choices, “the choices we make every day.”

First off, it’s important that older people not put themselves out to pasture. They must actively combat the low expectations our societies have for them. In rapid fire, he issued a set of maxims: “Maintain physical and cognitive function. Continue engagement with life. Minimize risk of diseases and disabilities. Don’t be isolated in your home.”

Specifically, he called on older people to move a lot; engage in quick learning — “not coasting or settling” — to stimulate new neural pathways; maintain a strong social network in order to reduce the risk of major diseases like cancer, diabetes, and dementia; find a role and higher purpose — it can be small or big thing, but we “wither without purpose”; take on a slower pace, avoid clocks, and practice mindfulness to reduce chronic stress; eat a Mediterranean diet; create inter-generational connections, particularly with young kids; laugh a lot, which boosts the immune system; engage in creative pursuits in order to “be in the moment”; and be close to nature.

Many of these life-preserving behaviors have been documented in Dan Buettner’s book Blue Zones: 9 Lessons for Living Longer from the People Who Have Lived the Longest about the “living labs,” the unique communities around the world that have high numbers of incredibly vital 90 and 100-year olds. These communities maintain important features of the lifestyles of our prehistoric hunter-gatherer ancestors. Landry said we make mistakes when we veer too far from ancient wisdom.

As the boomers retire, a new approach, rooted in a less-ageist mindset, is needed. “Can we make acting your age a bad thing? As a society, we must change how we see aging. Age should be irrelevant.”

In the past, there has been “too much human capital warehoused in facilities.” We can’t waste the potential contributions of 76 million aging baby boomers and many millions more around the globe.

Over the past few years, AARP has become a much more vocal advocate in Washington, D.C. for walkable, affordable communities for seniors, and, well, everyone, but they have recently put the full weight of their 38-million-member organization behind livability, with their new Livable Communities Index, which was announced at the American Planning Association conference in Seattle. Given how powerful AARP is on Capitol Hill and in state legislatures around the country, this is a boost for all of us focused on reducing the real social, economic, and health costs of car-dependent, sprawled-out communities. At all levels, AARP is pushing for policies that support aging in place, which is what their research tells them 80 percent of seniors want to do.

AARP argues that a livable community has “affordable and appropriate housing, supportive community features and services, and adequate mobility options, which together facilitate personal independence and engagement of residents in civic and social life.” Furthermore, a livable community is a place where “please can get to go where they want to go, living comfortably and in good health, and being able to remain active and engaged.” With this new focus on livable communities, AARP argues that what is good for older Americans is for good for all. For example, a recent report produced by Smart Growth America, with AARP and ASLA, called Dangerous by Design examined how the lack of safe sidewalks in so many communities has lead to the unnecessary deaths of 47,000 both young and older Americans. Good sidewalks benefit everyone.

The new livability index, which measures communities capacity to offer these elements, is rooted in a national survey of 4,500 Americans 50-plus, which found that older Americans want the following things the most: a strengthened police presence, improved schools, more walkable streets, better transportation options for seniors and the disabled, and more high quality parks. Using the survey responses, a team of experts selected 60 factors across seven categories — housing, neighborhood, transportation, environment, health, engagement, and opportunity — to create the index, which weighs data from 50 sources.

This result is an easy-to-use tool that enables anyone to plug in an address or zip code to determine how livable their community is. According to AARP, the average community scores a 50. When I typed in my neighborhood in Washington, D.C., it got a score of 60, barely in the green or livable section. My neighborhood scored poorly on a few metrics, like the number of days with bad air quality and heavy street-level car pollution, the lack of affordable housing, and the high rates of inequality. After exploring the metrics, users can look into whether their neighborhood or community has policies that improve livability. For example, for my neighborhood, the index reported that there are no local housing accessibility or affordability laws. Urban planners, landscape architects, and policymakers can further customize the tool, weighing some factors more heavily than others.

AARP also released their list of the 10 most livable neighborhoods, and 30 most livable cities in the country, separated into large, medium, and small-sized cities. For their respective categories, the top cities are San Francisco, California (70); Madison, Wisconsin (68); and La Crosse, Wisconsin (70). Running a number of their top-ranked neighborhoods through the index, it appears that a top score is around 70. As AARP says in their video above, almost every community has a ways to go to meet their definition of livable.

The senior population is growing. By 2050, a third of the U.S. will be 65 and older. The World Health Organization, AARP, and other organizations have called for more age-friendly communities, with parks and open space that offer what seniors needs to feel safe, but not enough are heeding their call. One question that came up in a session at the American Planning Association (APA) conference in Seattle is whether future parks need to be designed to be inter-generational, or designed specifically for the elderly. Two academics and a landscape architect argued the research shows seniors do better when they are around all age groups, but they need specific things to feel safe and comfortable in parks and other open spaces. If they don’t have them, they are far less likely to venture into these places.

Lia Marshall, a PhD student at the Luskin School of Public Health, University of California Los Angeles (UCLA), said older adults have a preference for “aging in place,” meaning staying in their community. They need independence. This group — like any other broad category — is amazingly diverse, both socially and culturally. Walking is their most common physical activity, so “distance to the park affects use.” But many older people are also at the risk of isolation, which can result in mental health problems. This group is also among the least active, which can also lead to physical health issues.

Parks are too often created for children or able-bodied adults. But they can be designed with a set of aging principles. Through a set of 8 focus groups conducted with elderly about their park use in Los Angeles, Marshall found that they all share “an enjoyment of natural beauty, with an appreciation for tranquility, plants, and fresh air.” Being in a park encouraged social interactions, which led to more physical activity. “Group activities — like Tai Chi in the park — lead to friendships and more exercise.”

But the elderly polled were also fearful, with their greatest fear being falling. “Breaking a hip can mean losing their homes and moving into a retirement facility.” For them, other primary threats were “disrespect by younger generation, robbery, drugs, and crime.” Environmental threats include: “uneven ground surfaces, trash caused by the homeless, a lack of visibility with walking paths, a lack of shade, and excess heat or cold.” Those with canes, walkers, and wheelchairs feel even more vulnerable outdoors. Marshall pointed to a park right next to a senior center in Los Angeles that wasn’t used by the elderly because “gang members are there.” Overall, “seniors are afraid of their communities but also want to be involved.”

Improve control: Provide orientation and way finding with large, visible fonts. “The park layout needs to be legible.” Signs should be 54 inches off the ground or lower, so people in wheelchairs can also see them.

Offer greater choice: “Everyone values options, such as passive or active recreation, sun or shade, single or multiple seating. Chairs should be movable.” Brozen emphasized that the group older than 65 is incredibly diverse, from “not old to advanced dementia,” so they have different needs.

Create a Sense of Security: “There should be shade but not too much so it feels enclosed.” Parks should enable “eyes on the street.” Isolated areas need good maintenance. Sidewalks should be wide and smooth. Check spaces between paved and unpaved areas to make sure there aren’t spots where a cane or wheelchair can get caught.

Accessibility: If a park is a good distance from a senior facility, add benches along the way so there are place to stop. Parks should have no more than a 2 percent grade for those in wheelchairs.

Physical activity: Parks should also feature mile markers for encouragement. “These kinds of things are low impact, high benefit.” Exercise machines should be under shaded areas.

Privacy: Use buffer plants to reduce street noise.

Nature: Bring in water features, which are relaxing and beautiful. Make sure they are wheelchair accessible. And lastly, parks should highlight natural beauty.

For Portland-based landscape architect Brian Bainnson, ASLA, Quatrefoil Inc, and ASLA Oregon Chapter Trustee, there is even more that can be done, beyond A.D.A. requirements — and, really, the guidelines listed above. “ADA is really just the bare minimum. It leaves out so many users.” Bainnson said when designing for seniors, “you are really designing for everyone, but there are other hazards you have to be aware of.” For example, contemporary parks often feature these sleek, backless, armless benches that are essentially useless for the elderly. “Without an armrest, they can’t lower themselves into the bench or get out of it, so they just won’t use it.”

Plants should appeal in all four seasons. Park and garden designers need to be aware of wind direction and the sun path to create both wind-free and shaded areas. He added that designers must reduce sharp differences between light and dark. “Hip fractures from falling can occur as the elderly navigate the transition from deep shadow to bright light. They think it’s a step and they can trip up. There should be a middle ground, a transition zone.”

Bainnson has designed more than 20 therapeutic landscapes, including the Portland Memory Garden and parts of the Legacy Emanuel Children’s Garden. The Portland Memory Garden, which is designed for users with Alzheimer’s or other forms of dementia as well as well as their care-givers and families, is an enclosed loop, with a central entrance and exit, which is not only soothing to those suffering from dementia but ensures they don’t wander off.

The single entrance and exit means nurses or family members can also keep an eye out from a central place. Built in 2002 with $750,000 in privately-raised funds, the Memory Garden has “no dead ends or choices. You just follow the curve.” Concrete pathways are tinted to reduce glare. Their outer edges have a different color. Raised curbs on the edge of the sidewalks help ensure users don’t fall into the lawns. Bathrooms are extra large in case nurses or family members need to go in with someone in their care.

For true open spaces, seniors also have special needs. Bainnson is now working with the U.S. Fish and Wildlife Service on national wildlife refuges near Portland to make them more accessible to seniors, by putting in trails, accessible paths, and readable signs. He said they may not be able to access the whole system — as the city wants to keep the trails as natural as possible — but these steps will make it easier.

Marshall, Brozen, and Bainnson all made the case: consider seniors when designing public spaces. Why exclude? “What works for seniors will work for everyone.” These spaces will also work for all those people with any other cognitive or physical challenge, like veterans dealing with PTSD, people with prosthetic legs, or anyone in a wheelchair.

More than 47,000 people were killed while walking in the U.S. between 2003 and 2012, a rate that has been rising in the last few years. The majority of those deaths could have likely been prevented with safer street design, according to Dangerous by Design 2014, a new report released today by the National Complete Streets Coalition, a program of Smart Growth America, in conjunction with AARP and American Society of Landscape Architects (ASLA).

The report also ranks America’s major metropolitan areas according to a pedestrian danger index that assesses how safe pedestrians are while walking. The four most dangerous — Orlando, Tampa, Jacksonville, and Miami — are all in Florida. The others in the top-10 most dangerous list are: Memphis, Phoenix, Houston, Birmingham (new to this year’s top 10), Atlanta, and Charlotte.

“We are allowing an epidemic of pedestrian fatalities — brought on by streets designed for speed and not safety — to take nearly 5,000 lives a year. This number increased six percent between 2011 and 2012,” said Roger Millar, director of the National Complete Streets Coalition. “Not only is that number simply too high, but these deaths are easily prevented through policy, design, and practice. State and local transportation leaders need to prioritize the implementation of complete streets policies that keep everyone safe.”

More than 676,000 pedestrians were injured over the decade, equivalent to a pedestrian being struck by a car or truck every eight minutes. That rate increases significantly for more vulnerable populations such as older adults, children, and people of color.

While just 12.6 percent of the total population, those over the age of 65 years old account for nearly 21 percent of pedestrian fatalities nationwide. “Older persons account for one in every five pedestrian fatalities and have the greatest fatality rate of any population group,” said AARP Executive Vice President Nancy LeaMond. “America’s state, federal, and community leaders should focus on making our streets safer, which will benefit everyone, including the growing number of older Americans.”

Children 15 years and younger represent a significantly at-risk population, and fatal pedestrian injury remains a leading cause of death. Between 2003 and 2010 (the most recent year for which data is available about children), 4,394 children were killed while walking.

Among people of color, blacks and African Americans suffer a pedestrian fatality 60 percent higher than non-Hispanic whites, and Hispanics of any race have a rate nearly 43 percent higher.

The majority of pedestrian deaths occur on roadways that encourage speeding, and speeding is a factor in nearly one-third of all traffic fatalities. The report finds that these deaths can be prevented through changes to the design of our streets: providing sidewalks, installing high-visibility crosswalks and refuge islands, and calming traffic speeds.

This has proved true for roads such as NE 125th St. in Seattle, WA. In 2011, the city added a marked crosswalk, reduced the number of travel lanes, and installed bike lanes, along with other measures, to provide for the safety of pedestrians in a high-crash corridor where 87 percent of drivers were speeding. The modifications have reduced the rate of collisions by 10 percent and speeding by 11 percent and led to more people walking and biking along the roadway.

“More and more Americans are choosing communities that are walkable and accessible for pedestrians, children and older Americans, but that shouldn’t be a luxury,” said Nancy Somerville, Executive Vice President & CEO of ASLA. “Simple and affordable additions or retrofits to traffic signals, pedestrian islands, and sidewalks can make a huge difference in safety and protection.”

The report recommends states take action to improve safety for pedestrians in communities nationwide:

Increase the available funding and maximize the use of existing federal programs for walking and bicycling projects.

By 2050, one in five Americans will be 65 years of age or older, but, unfortunately, less than half of our country’s jurisdictions are prepared for this massive demographic shift. At The Atlantic’s “Conversation on Generations” forum at the Newseum in Washington, D.C., Steven Clemens, Washington editor-at-large of The Atlantic and Richard Florida, author of The Rise of the Creative Class and other bestsellers, discussed how communities can better prepare for their aging populations. The big point they made: what makes these communities healthier for older people will really benefit Americans of all ages.

Florida defined aging baby-boomer populations as Empty-Nesters, those 45-64, and retirees, those 65 and older. These groups are now replicating the trends of the Millennials: they are moving to urban centers. Boomers are moving to cities to be closer to their children and grandchildren. In part, they may be moving there to build a sense of community that may be missing in the suburbs.

But at least with the aging, the differences between the suburbs and urban areas may not be so stark. Florida said the traditional “categories of city and suburb don’t cut it anymore.” The distinction is now between whether a community is livable or not. A livable community is safe, secure, and offers access to transit, health care. These places are walkable and enable a high level of sociability. All of these things combine to help people age in place. According to the AARP, this is something the vast majority of older Americans want to do.

Clemens added that “cities have become better at being cities,” but there is still work to be done to make the majority of our communities truly livable. Transit systems need to be expanded or built in the majority America’s communities. Improving the connectivity of neighborhoods via networks of sidewalks and bike lanes is important. And the things that used to draw people downtown, “the SOBs – symphony, opera and ballet,” as Florida jokingly called them, aren’t enough of a draw anymore. Boomers and Millennials alike both call for more street-level vibrancy.

Florida admits this move by the boomers to urban centers, rather than retirement communities set in warmer climates, may lay the “seeds of generational conflict,” simply because boomers have more money and freedom of movement and can therefore potentially squeeze out younger people in their 20s and 30s.

That said, it isn’t just older people who will benefit from what Clemens called the “density and connectivity” of these livable communities. Florida noted that 33 million Americans across all age groups live in solo households. The more social ties a person has between friends and family, the longer and richer their life will be. Older Americans are more and more looking to live among a diversity of ages and experiences, which living in urban centers can give them.

While livable communities allow older people to age in place, the assets that allow them to do it with dignity – sociability, walkability, access to affordable and quality healthcare, proximity to community parks and greens spaces – are also the things that make cities healthy and livable places for people of all ages. “Cities are not just places and built environments, they are collections of people,” said Florida, also noting that, “the places that really do well, do well across the board.”

Dr. Richard Jackson, Professor and Chair of Environment Health Sciences, UCLA, said the built environment in the U.S. was designed in a way that is “fundamentally unhealthy” in a talk at the New America Foundation, a think tank in Washington, D.C. The environment is now making it difficult for people to achieve well-being. It’s getting so bad that this generation growing up may be the first in American history that has “a shorter life span than their parents.” Communities have to be redesigned to “make us all healthier – young or old.”

Host of the new four-hour PBS series Designing Healthy Communities, author of the series’ companion book, and co-author of a more in-depth text book, Dr. Jackson knows what he’s talking about. Primary care doctors, he said, are now inundated with young, overweight, depressed patients. These kids are sent to weight loss programs, told not to watch TV, and drink less soda, but they can’t really lose any weight because “they have no place to walk.” So, “two months later” they are loaded up medications to deal with their weight, anxiety, depression at a cost of about $400 a month. This is the part the medical community is missing: “These are environmentally-induced diseases. The environment is rigged against kids, doctors, communities.”

Now, 18 percent of the U.S. economy goes to healthcare, which is more than the country spends on defense. Among developed countries, the U.S. now ranks 47th in terms of average life span. Meanwhile, Costa Rica, whose population has about the same life span as the U.S., spends seven times less per person than the U.S. While the U.S. life span rates have improved (30 years has been added over the past 110 years), only “five years can be attributed to the work of doctors.” The rest of the gains come from immunizations and “infrastructure” that helped defeat diseases like tuberculosis.

These days, the challenge is chronic disease caused by our shared environment: asthma, obesity, diabetes, along with mental disorders like anxiety and depression. Jackson, who (amazingly) lives in Los Angeles without a car, said “people are now appendages to their cars” so it’s no wonder these diseases have skyrocketed. People are isolated and communities are broken, largely because people now have car-centric lifestyles and there are no longer any real community spaces in the average suburban subdivision. The result: “Antidepressants have increased 400 percent over 20 years.” Jackson thinks this number shows how the power of community to undo depression has itself been totally undone. “For thousands of years, community has gotten us through depression. Unfortunately, we’ve unravelled our communities.” Jackson also said what landscape architects have always known: getting out and walking in green spaces is about as effective as antidepressants (that is, if people can get to them).

Dealing with diabetes now takes up 2 percent of the GDP of the country given that in many states almost 10 percent of the population has the disease. By 2050, that number is expected to grow to more than 20 percent. Obesity is another, well, big problem: In comparison with past generations, the average American is now 25 pounds heavier and the average kid, 14 pounds heavier. In some states, 30 percent of the population is severely obese. The problem is particularly depressing with kids, but, again, one can point directly at the built environment as a primary cause of the weight gain. “One generation ago, 2/3 of kids walked or biked to school. Now, it’s 1 in 8.” On top of that, the country subsidizes soy and corn products to be used in highly processed foods, but doesn’t do the same for fruits and vegetables. “In fact, if everyone at the surgeon general’s daily recommended amount of fruits and vegetables, the country would run out in three days. We just don’t have the produce available. This is why it’s so expensive.”

Jackson believes that every school should have a garden and every community should have a farmer’s market. Walkable green spaces should be used to fight mental health issues. Kids should live in walkable, bikeable areas so they can further their own “autonomous development.” Moving up in scale, cities can create active design guidelines like New York City has, and states can even incorporate healthy community designs into their planning efforts.

These health arguments are more powerful than the wonkier ones related to transportation financing or economic development, said Christopher Leinberger, a professor at the University of Michigan, smart growth developer, and writer for The Atlantic. Still, he thought it was odd that “public health people and nurses get these ideas,” but doctors still don’t.

While many doctors need to be brought around, many communities may be realizing they can affect change on their own, and put pressure on elected officials and planners to do things differently. AARP certainly thinks so. The organization, said Amy Levner, who manages their mobility programs, is now focused on supporting local activists in improving quality of life for those over 50. Now active in the Complete Streets Coalition, AARP is financing “pedestrian audits” that help figure out the obstacles that prevent people from walking. For this group, one of the most powerful in D.C., it’s about improving quality of life for older people who are “past their driving years.” But what’s good for those older folks will be good for all.

Shannon Brownlee, Health program director, New America Foundation, said siloed policies have meant that policymakers haven’t realized all the end costs of their decisions. For example, subsidizing unhealthy foods just passes the costs onto people and the healthcare system. “We don’t think of the costs to health – on the other end.” Indeed, according to Leinberger, the problem just continues at the federal level. Few on Capitol Hill are thinking of the health or economic costs of the transportation bills now being considered, which simply push forward the same old model: 80 percent of funding for highways, and 20 percent for “alternative” transportation. Leinberger said that “alternative” financing, which sounds like something marginal, devious, actually covers “all transportation networks in cities,” things like pedestrian and bicycle infrastructure.

In the Senate, which is a “rural body” even though it’s run by Democrats, “most still refer to this as the highway bill.” Leinberger didn’t seem to be hoping for much, just that “transit-oriented development and mixed-use development is made legal. Currently, it’s illegal.” He also rang a hopeful tone by saying that the market will eventually succeed over dysfunctional Washington.

This is because there’s a 40-200 percent premium for walkable, well-designed communities. “The market desperately wants this. There’s 30 years of pent-up demand.” He said some 56 percent of the U.S. wants to live in these communities but maybe only 20 percent actually do. So even though the new transportation bill is actually “going the wrong way” by incentivizing more highways, the market will eventually “get what it wants,” overcoming any obstacles the federal government puts in the way.